Photo and Media Release

Clinical photographs are part of your record either way

Clinical photographs are always part of your dental record and are used for diagnosis, treatment planning, and your chart, regardless of the choice you make below. That use is part of your treatment and is covered by the Notice of Privacy Practices. This release covers only additional, optional uses.

What you would be permitting

If I opt in, I grant Esthetique Dentistry of Ashburn permission to use my photograph — smile only, or whole face, according to the selection I make — on the practice's website, in printed materials, and on social media.

I understand no payment will be made to me for this use.

This is entirely optional

Declining has no effect at all on my care or on the treatment available to me. I may opt in now and change my mind later.

Withdrawing permission

I may withdraw this optional consent at any time by notifying the office in writing. The practice will stop using the photograph in new materials, and will remove it from pages it controls. Withdrawal cannot affect materials already printed and distributed, or copies already shared by others on social media.